LU IV SUBSTANCE ABUSE - Jan 2011

8/8/2019 LU IV SUBSTANCE ABUSE - Jan 2011

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Substan

Use

Joselito C. Pascual, MD, MSc, FPSCOT,

ABUSE Dependence

intoxication


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3.4 million Filipino illicit drug users (UPPIS, 2002)

8,189 admissions (DDB, 2003)

Discrepancy in the incidence andadmissions underscores thepossibility of addressing the

magnitude of the problem at the

tip of the iceberg.


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OBJECTIVESTo discuss

The available drugs of abuseThe philosophy associated with

biopsychosocial approach in terms of:

effects, consequences and treatmentThe target population: Drug Users

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Pinang,

nga-nga

Areca Nut

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ARECA NUT: Contextof use

Cultural meaning:

Used in important ritual inrestoring harmony and peacebetween individuals or within a

community

Stimulatory andeuphoriant effect ** Herbal PDA, 2000; Weiss and Fintelmann, 2000

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Causes the teeth to turn black-brown

and stains the tongue and oralmucosa

Use has been associated with oralcancer *

* Mangla betel nut warning. Lancet1993;341:810-819

BETEL NUT

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BETEL NUT

Arecoline: a cholinomimetic alkaloid A potent diaphoretic

Stimulates the salivary, lacrimal, gastric,pancreatic, intestinal and the mucosal cells ofthe respiratory tract

Increases muscle tonus and muscle movement

throughout the body Mimics the action of acetylcholine in

the body

Slows the heart rate, constrict the pupils of theeyes

Shanon M., Herbal, tradittional and alternative medicine in Clinical Management of Poisoning an Overdose. Haddad,

Shanon and Manchester (eds) 2006

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Daturametel

(angels trumpet, talampunay)

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Common uses and properties: Asthma

Adverse effects:

Hallucinogenic, anticholinergic effects*

*Herbal PDA, 2000

Datura metel(angels trumpet, talampunay)



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Daturametel

(angels trumpet, talampunay) PLANTS

Family Solanaceae: Genera Atropa, Datura, Hyoscyamus,

Lycium, and Solanum Principal alkaloids: solaninine, atropine and

scopolamine

PHARMACEUTICALS Antiparkinsonian agents: trihexyphenidyl and benztropine

mesylate (euphora and hallucinogenic effects):Havepotent dopamine reuptake inhibition with excess indopamine (craving)



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MUSHROOMS

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MUSHROOMS: Context ofuse

Food

Religious ceremonies

Medication by herbalhealers

Substance of abuseShanon M., Herbal, tradittional and alternative medicine in Clinical Management of Poisoning an Overdose. Haddad,



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Aga, Shrooms

Amanita Muscaria

Adverse effects: Dizziness, vomiting, abdominal pain, movement disorders,

muscle cramps, psychic stimulation, followed by deep sleep,confusion, mania, unconsciousness, coma and, death*

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Amanita muscaria

Contain cholinergic alkaloid muscarine(structurally similar to acetylcholine)

Many cases of poisoning occur in individuals who

deliberately seek and ingest the mushroom for itshallucinogenic properties (purposeful ingestion ofurine from people who have eaten thesemushrooms has been reported as a way to elicitthe psychoactive effects of the excretedmuscimol).

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Cannabis sativa and indica plants

5000 years ago.

Alleged anti-emetic, anti-convulsant, anti-

anxiety, analgesic, anti-inflammatory

properties.

The Misuse of Drugs Act 1971

Cannabis oil (class A)

Cannabis resin or grass (class B)

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Nicotine

Effects mediated through nAChRs in the brain (VTA, NA)

Exposure results to activation then desensitization of nAChR >tolerance

Chronic exposure:

increased nAChR (slower turnover ofdesensitized receptors) > recovery

(desensitization) > hyperexcitable nicotinic system

1st cigarette: most pleasurable

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Nicotine releases

Dopamine

Norepinephrine

Acetylcholine

Vasopressin

Serotonin

Beta-endorphins

Pleasure, appetite suppression

Arousal, appetite suppression

Arousal, cognitive enhancement

Memory improvement

Mood modulation, appetitesuppression

Reduction of anxiety and tension

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Alcohol and the Filipino

Culture Many Filipinos hang out together

in the streets, in front of their

houses and stores especiallyamong urban poor and rural

communities.

Filipinos from the middle and

higher-income bracket drink at

bars.

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Drinking among Filipinos

Beer: still a favorite among Filipinos

Accounts for 15% of the Philippines 4billion-bottles-a-year market.

Source: Health Action Information Network, 2006

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Confined to small scale production

due to influx and supremacy of

commercial drinks

Lambanog (coconut wine)

Tapuy (rice wine)

Basi (sugar cane wine)

Tuba (palm wine)

Native DrinksSource: Health Action Information Network, 2006

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0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50

Jinro

Stolichnaya

Moskovskaya

Ginebra San Miguel

Pirassununga 51

Bacardi

Smirnoff

Russkaya

Tanduay

Kyoungwoul

2005 Worlds Top 10 Spirits Companies. Impact (2005) Vol. 35, No.22.

The Impact Databank, a US alcoholic

beverage research firm, cited the

Filipinos as worlds top gin drinkers

Ginebra San Miguel is the top gin brand

in the world in terms of sales at 27.4

million cases or P12 billion.

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A

LC

OHO

L Action on receptorsites inthe VTA

Action on GABA receptorsresembles that of

benzodiazepines (increase inGABA neurotransmission)

Antagonist effect of somereceptors for the excitatory

neurotransmitterglutamate(NMDA)

Increase release ofdopamine

in nucleus accumbens Stimulation of 5-HT receptors

(serotonin)

Koob G, Le Moal. Drug Addiction, dysregulation of reward, and allostasis. Neuropsychophramacology 2001; 24:97-129

Nutt D.Alcohol and the brain. Pharmacological insights for psychiatrists. Br J Psych 1999; 175:114-19

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Rx

Sedative-hypnotics

Opiates

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CL-Cl-Cl-

BENZODIAZEPINE

GABA

Binding to GABA A receptor

GABA coupling to Transducer

(G protein)

Opening of

Chloride ion channels

Neuron hyperpolarization

RMP stabilization

Dampening of

Neuronal Excitability

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Koob G, Le Moal. Drug Addiction, dysregulation of reward, and allostasis. Neuropsychophramacology 2001; 24:97-129 Nutt D.Alcohol and the

brain. Pharmacological insights for psychiatrists. Br J Psych 1999; 175:114-19


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CLUB DRUGS


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The Current Drug Scene

Cocaine

Alcohol

Methamphetamine

Nicotine

Designer drugs

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1. Lit E. et al. The Epidemiology of Substance Use. In:Sourcebook of Substance and Addiction. Friedman L

and Fleming N. 20032. Kaufamn & Friedman,1996; Haut & Rovere, 1984)

Stimulating properties of Ephedrine by theChinese 5000 years ago

Introduction of amphetamine, a syntheticanalogue of ephedrine in 1932 as an appetitesuppressant

Limited therapeutic use to the treatment ofattention deficit-hyperactivity disorder (ADHD)

Amphetamines:

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CH2 CH NH2

CH3

CH2 CH NH

CH3CH3

Amphetamine

Methamphetamine

Indirect monoamine agonists with bothcentral and peripheral actions

Release of norepinephrine, serotonin,

dopamine from presynaptic terminals

Mechanism of Action

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KetamineK, Special K, Vit K, Cat valiumsHigh doses:

delirium, amnesia, impaired motor

function, respiratory depression

- Low doses:

impaired attention, learning ability

and memory

club

drugs

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club

drugsEcstasy(3,4- methylenedioxy-n- methylamphetamine)

XTC, X, E, Adam, Clarity, LoversSpeed

Euphoria, comfort, empathy HR and BP,cognitive impairment

Cocaine(benzoylmethylecgonine)Mood elevating

High doses: irritability, psychosis,seizure, unconsciousness, coma

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WHY DRUGS?

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Normal

Effects of Drugs

USE Rush

Intoxication

Withdrawal

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Epidemiology of Use

Initiation of Use

As a normal consequence ofdevelopment of adolescents attempt to

assert their individuality whileconforming to peer norms

Separation from family

Membership within a social group Peer-sanctioned illicit activities life transitions

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Gail C et al. The Epidemiology of Substance Use. In:Sourcebook of Substance and Addiction. Friedman L and Fleming N. 2003


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Epidemiology of Use

Initiation of Use

Substance use is aprogressive process

beginning with alcohol and cigarettes,progressing to recreational licit and illicit druguse, marijuana, and then to hard-core drug use(each stage not invariably followed by the next).

Social forces (peers, parents, siblings, familydynamics, psychological profile and popularculture).

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Popular Culture

creation of several images ofdrug use driven byadvertisements, television,movies and music videos.

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Wyszynski A, Yu V.: Patient using steroids, Manual of Psychiatric care for the

Medically Ill. Am Psych Press 2005


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DRUGS OF ABUSE:Sought After Effects

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Lit E. et al. The Epidemiology of Substance Use. In: Sourcebook of Substance and Addiction. Friedman L

and Fleming N. 2003

weight reduction anti-fatigue, activity sustaining

effect

performance enhancing effects


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DRUGS OF ABUSE:Sought After Effects

Marked individual differences Relief of anxiety

Intoxication and relaxation Alertness

Mood elevation

Some individuals who use drugs in ordinarycircumstances eventually increase their

dosage to develop misuse

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Lit E. et al. The Epidemiology of Substance Use. In: Sourcebook of Substance and Addiction. Friedman L

and Fleming N. 2003


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Epidemiology of UseCategories of Use

Those who inject intravenously orsmoked ICE

Individuals who switched to amphetaminesfrom other IV drugs;

Polysubstance abusing individuals;

Those who previously used oralamphetamines;

Experimenting adolescents and young adults jcpascual 2011Gail C et al. The Epidemiology of Substance Use. In:Sourcebook of Substance and Addiction. Friedman L and Fleming N. 2003

D d d


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Drug, drugs anddrugs:

Polysubstanceuse

Self-detoxification Stimulants: Benzodiazepines and alcohol

taken to alleviate stimulant withdrawal

Alcohol: to modulate and enhanceeffects

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Bearn J. Sedative hypnotics , 2004; Wolff K, Barbiturates and sedative-hypnotics, 2004;

Gossop et al. ,1991; Preston et al., 1984.


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Deliberate Self-harm

Stahl S., Essential Psychopharmacology of Antipsychotics and Mood Stabilizes,

Cambridge University Press, 2002.

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The Medical paradigm in Substance

Use, MisuseandDependence

Anxiety

Depressi

onPsychosis


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Tegm

entum

The dopaminergicpathways of the brain

Increased levels of dopamine in the NAcritical in mediating rewarding effects orpositive reinforcement for drugs of misuse(Koob and Le Moal, 2004)

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Substantia

nigra

Nigrostriatal

Dopamine pathway

Basal ganglia

Hypothalamus

Tuberoinfundibular

Dopamine pathway

MesocorticalDopamine pathway

Mesolimbicdopaminepathway


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AMPHETAMINE

Reduced dopaminergic functioning in the

mesolimbic system,D2

receptor levels(withdrawal, early abstinence up to4 months)(Volkow et al., 2003)

Dysphoria, anhedonia, irritability,craving,

drug-seeking behaviour.

1. Lingford-Hughes A, Nutt D. Neurobiology of addiction and implications to treatent. B J Psychiatry 1999; 175: 114-119.

2. Schultz W. Reward signaling by dopamine neurons. Neuroscientist 2001;7:293-302.

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The Downside ofDrug use

UseRecreational use

and Reward

Tolerance(adaptive processes in the brain

that diminishes the effects of

drug)

Abstinence

Adaptations(sensitization, craving,

cues)

Unopposed

Compensation Process

Withdrawal(Unpleasant symptoms)

Continued drug useto ward off pscyhological and

physical symptoms(Dependence)

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emergency

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Reasons for

entry intoHealth System

Associated trauma

Overdose (accidental, suicidal)

Panic reaction ( bad trip ) or significantintoxication

Inappropriate behavior

Drug-seeking behavior (withdrawal) Coerced by the legal system


Specific symptoms


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p y pencountered with

Recreational Substance Use

DisorientationConfusion

Destructive and assaultive behavior

Depression

HallucinationsDelusions

Trauma

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General


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e m e r

e m e r g e n c y

e m e r g e n c y

e m e r g e n c y

e m e r g e n c y

e m e r g e n c

GeneralApproach

Emergency stabilization

Clinical evaluation

Elimination of the drug/drugs

Excretion of the absorbed drug/drugs Administration of antidotes and/or

pharmacotherapy

Supportive therapy and observation

Disposition

TOXICOLOGY

er

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I t i ti d


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Intoxication andOverdose

proceed with basic ABCs of life support

management of medical emergency

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I t i ti d


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emergency stabilization:

airway obstruction, breathing difficulties,circulatory inadequacies, drug-induced CNS

stimulation or depression, electrolyte or metabolicabnormalities

Establish etiology general management: Diazepam 5 mg IV foragitation,

restlessness or seizures


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D E T O X I F I C A T I O

N


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psychicagitation:

Diazepam 5 mg oral/parenteral1st generation antipsychotic: Haloperidol 2

mg deep im


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CLINICAL ISSUES


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CLINICAL ISSUESwith drug use

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TOXICOLOGY

Single drug or a mixture?

Illicit amphetamine or prescriptionsor both?

Drug-drug interaction or cocktail ofdeath?

TOXICOLOGY

LONG TERM ISSUES


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LONG-TERM ISSUESwith drug use

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TOXICOLOGY

Psychological

deterioration

Psychosocial deterioration

PSYCHIATRY


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The DOWNSIDE

of recreational drug use

C O N C L U S I O N

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The DOWNSIDE


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The DOWNSIDEof substance Use, Misuse and

Dependence

while rates of drug use have remained stable ordeclined, recreational drug use among Filipinos has

reflected current trends in recreational drug use inFilipino society.

although young Filipinos may limit their recreational

drug use, which is associated with lower rates ofimpairment and addiction, such recreational use may

progress to use of higher-risk drugs.

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Theories of addiction have mainly been developed from

neurobiological evidence and data fromstudies of

learning behavioursand memory

mechanisms. They overlap in some aspects and are not mutually

exclusive.

Continued use induces adaptive changes inthe central nervous system that lead to tolerance, physicaldependence, sensitization, craving, andrelapse.

The DOWNSIDE

of drug use

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The DOWNSIDE


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The DOWNSIDEof recreational drug

use This session discussed substance abuse as well as the

dangerous side effects of recreational use, some ofwhich are irreversible.

It is hoped that this may eventually encouraged health

workers to persuade users to quit and preventindividuals from initiating use.

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THANK YOU

LU IV SUBSTANCE ABUSE - Jan 2011

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